Provider Demographics
NPI:1194034264
Name:BLALACK, BILL E (RPH)
Entity Type:Individual
Prefix:
First Name:BILL
Middle Name:E
Last Name:BLALACK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 S WHITWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-3343
Mailing Address - Country:US
Mailing Address - Phone:601-835-0370
Mailing Address - Fax:601-835-3376
Practice Address - Street 1:218 S WHITWORTH AVE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-3343
Practice Address - Country:US
Practice Address - Phone:601-835-0370
Practice Address - Fax:601-835-3376
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-06
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD05554183500000X
MS5911183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist